IDIO8zICL JON] PATHOLOGICAL SOCIETY OF LONDON. [QCT. 21, 1899.

It had been suggested that the peculiar congested colour ofthe umbilicus was due to compression of a persisting umbilicalvein. This was found to be correct, and at the necropsy Iwas interested to find a large vein filled with clot, passingupwards from the umbilious to the liver.

P. CLENNELL FENWICK, M.B.Lond., M.R.C.S., L.R.C.P..Surgeon to the Christchurch Hospital, N.Z. _

REPORTSON

MEDICAL AND SURGICAL PRACTICE IN THEHOSPITALS AND ASYLtTMS OF THE

BRITISH EMPIRE.

NEWCASTLE ROYAL INFIRMARY.ENCYSTBD VESICAL CALCULUS.

(By FREDERICK PAGE, Surgeon to the Infirmary.)MY object in reporting this case is that it admirably illustratesthe point laid down by Mr. Bruce Clarke in his excellentpaper published in the BRITISH MEDICAL JOURNAL of May13th-namely, where symptoms of cystitis persist, resisting allordinary methods of treatment, even where the presence of astone is not revealed by sounding, suprapubic explorationwill frequently result in the-discovery of an encysted calculus.A man, aged 47 years, was admitted into the Newcastle

Royal Infirmary in June, I899. Ten years previously a stonewas removed by lateral lithotomy. Six months ago his bladdersymptoms returned, as indicated by the passage of a largequantity of blood by the urethra. Since this occasion therehas been no repetition of the bleeding, his complaint beingfrequency of micturition, great pain on defaecation, and, afterexcretion or straining, intense pain at the end of the Penis.On examination of the urine it was found to be neutral, andcontained a considerable amount of pus, but no blood. Onrectal examination there was great tenderness on either sideof the prostate, and on the right side a hard, irregular nodulecould be felt. The bladder was sounded on several occasions,and no calculus detected. With rest and irrigation of the blad-der the symptoms subsided, but returned in about a fortnight.Under an anesthetic, the bladder was again sounded, and no

stone could be felt. A suprapubic opening was thereforemade for purposes of exploration, and a small irregular cal-culus, about the size of a small bean, was found encysted be-hind and to the right of the prostate. On further examiningthe base of the bladder with the finger, a sharp point wasdetected near the site of the stone already removed, and thisturned out to be the point of a stone in shape exactly like anordinary tin tack, the whole of which was embedded in thesubstance of the bladder with the exception of the projectingsharp point. This curious calculus was enucleated with thefinger. All symptoms ceased, and the man left the hospitalfree from any inconvenience, and he continues to be well.

REPORTS OF SOCIETIES.PATHOLOGICAL SOCIETY OF' LONDON.

W. WATSON CHBYNE, F.R.C.S4., F.R.S., President, in theChair.

Tuesday, October 17th, 1899.AFTER an introductory address by thePRESIDENT, pointing outthe advantage attaching to the cultivation of pathology in allits aspects and the disadvantages that come from extremespecialisation and isolation, a communication upon two casesof Congo sleeping sickness was made by Dr. Patrick Mansonand Dr. Mott.

SLEEPING SICKNESS.Dr. MANSON briefly recalled the clinical characters of this dis-

ease. It was limited to certain parts of Africa, yet cases oc-curred, widely scattered in consequence largely of migration.Its period of latency was remarkable. The negroes held itslatency to extend over seven years, and probably correctly.Clinically there were three stages: First, one of physicaland mental languor; secondly, one of sleep and of iniffer-ence, though from this the patient admitted of being tempo-rarily roused; thirdly, to this there succeeded tremors,

emaciation, convulsions, and invariably death. In oneof the two cases death was attributable to hyperpyrexia;in the other to a series of epileptiform seizures.There was no impairment of reflexes and the eyes were in allrespects normal. In most cases there was a general enlarge-ment of lymphatic glands and the appearance of itchingpapules. It was stated that at times the hair, naturally darkblack in the negro, would turn light and red. The blood inthis disease had always been found to contain the filaria per-stans, and the distribution of this parasite was strictly con-fined to the areas where the disease was endemic. Yet againsta causal relationship it was to be remembered that this para-site in such districts was so common that it was present inhalf the negroes. In the Indians of British Guiana fMlariaperstans was frequentlypresent in the blood, but the evidenceas to the occurrence of sleeping sickness amongst them wasimperfect. Not only did the embryos of F. perstans and F.nocturna differ, but the adult worms did also; that of F. per-stans had a bifid tail. No evidence that the disease was bac-terial was forthcoming.Dr. MOTT related the results of the investigation of the

central nervous system in these two cases of Congo sickness,which he illustrated by means of lantern slides and micro-scopic specimens. The brain and spinal cord, pituitary bodyand spinal ganglia were examined. To the naked eye thetissues in Case I presented but little change beyond someslight thickening of the pia-arachnoid. The cerebral con-volutions were complex and not atrophied; the brain weighed54 ozs. The two hemispheres were of equal weight, andthere was no excess of fluid. In Case ii (the younger patient)the dura mater was found adherent to the calvaria. A con-siderable quantity of cerebro-spinal fluid was present. Thepia-arachnoid was somewhat thickened and opaque over theconvolutions. The base of the brain likewise showed thicken-ing and opacities of the pia-arachnoid. The weight of thebrain was 36 ozs. Neither of the brains showed flatteningof the convolutions, erosions on stripping the membranes, ordilated ventricleswithgranular ependyma. Thenervous tissuesbefore mentioned were removed so soon after death as to avoidpost-mortem fallacies. Portions of different parts of the hemi-spheres, cerebellum, pons, medulla, and cord, as also thespinal ganglia, were stained by the Nissl, Marchi, andMarchi-Pal methods after suitable fixation. The micro-scopical examination of these sections exhibited in both in-stances similar conditions. There was a lepto-meningitis andencephalo-myelitis. Throughout the whole central nervoussystem, but especially in the medulla and base of the brain,sections showed all the perivascular limits distended withmononuclear leucocytes. The left cerebral hemisphere inCase ir showed this condition in an especially markedmanner, which very probably accounted for the right-sidedfits from which this patient suffered towards the end of life.Sections were also stained for microorganisms by Gram's,Pfeiffer's, and other methods, but with negative results inthis agreeing with the negative evidence obtained by hr.Bullock, who examined the blood and lymphatic glands re-moved from Case ii during life. Some of the cerebro-spinal fluid removed from Case ii after death yieldedon culture various organisms, but this evidence wasof no value, since rigid precautions were not taken in obtain-ing the same; moreover, a large bedsore existed overthe sacrum. The general and special appearance of thenerve cells was as follows: In Case i the outline of thenerve cells and their arrangement appeared fairly normal,neither was it considered that the neuroglia cells weremarkedlyincreased. The columns of Meynert in the cortexcerebri were distinctly evident, thus contrasting with theappearance of the brain in general paralysis. The cells them-selves throughout the whole nervous system showed a uni-formly dull, diffuse, staining reaction, and in none of thecells were the Nissl granules evident. This change wasundoubtedly due to the hyperpyrexia during the last hoursof life. In Case ii the cells for the most part presenteda normal outline and exhibited Nissl granules on thedendrons and in the body of the cell. In the medulla,however, a considerable number of cells showed chromolyticchanges, and to a less degree changes were found in the motorcells of the anterior cornua. The cells in the left hemi-sphere showed degenerative changes in sections of the motor

OCT. 21, 1899.] CLINICAL SOCIETY OF LONDON. [TN Bmrz 1109MIEDICA JOU=A&

area, Meynert's columns were not distinctly visible, and manyof the cells seemed atrophied and broken up. Fibres: Sec-tions of the brain and cord were stained by Marchi andMarchi-Pal methods. Nothing abnormal was found in Case Iexeept perhaps that the tangential fibres were not so numerousas in the normal cortex cerebri. In Case ii there was obviouswasting of the tangential fibres in both hemispheres butespecially of the left. There was slight sclerosis of thecrossed pyramidal tracts of the cord, more marked on theright side, and also a number of recently degenerated fibreswere exhibited by the Marchi method. The arteries of thecentral nervous system exhibited no trace of endarteritis.In the choroid plexus there were numerous microscopicalpsammomata. The central canal of the spinal cord was filledup with proliferated glia tissue. The posterior spinal gangliashowed the same appearances around the vessels, but theganglion cells in Case I only showed the diffuse stain-ing of hyperpyrexia, and in Case II exhibited afairly normal appearance. Could the changes above re-ferred to account for the symptoms? The changes inthe left cerebral hemisphere of Case ii together withthe evidence of degeneration in the opposite crossed pyramidaltract agrees with the convulsions of the right side observedduring life. No doubt these convulsions were the expressionof the increased irritability prior to death of the cortical motorneurons. The symptoms which were, however, present inboth patients, and characteristic of the disease-namely, pro-gressive drowsiness and lethargy, and the progressive weak-ness in body and mind, without any distinct paralysisor mental disability-could best be accounted for bysupposing that the metabolism or functional activity ofthe neurons as a whole was affected injuriously eitherby some toxic product circulating in the blood or exist-ing in the cerebro-spinal fluid; that this toxic agent,whatever it might be, occasioned great proliferation of mono-nuclear leucocytes beneath the pia-arachnoid and in the peri-vascular lymphatics. It might, however, be supposed that thefunctions of the nervous system were affected by an inter-ference with their nutrient lymph supply, owing to the peri-vascular lymphatics becoming filled with leucocytes. Theliver, kidneys, lungs, pituitary body, spleen, lymphaticglands, and duodenum, were also examined. The resultswere for the most part, with the exception of the duodenumand lymphatic glands, negative. The lymphatic glands weremuch enlargedowingtogreat increase of lymphocytes. Sectionsof duodenum showed a large number of lymphocytes, anda proliferation of the same in the lymphoid nodules.These facts were of interest in contrasting this affection withgeneral paralysis, which by many authorities was still consi-dered to be a primary meningo-encephalitis; yet, althoughthe appearances of inflammation in this disease were asintense, and certainly more widespread, than any case ofgeneral paralysis which the speaker had seen, yet the cellularchanges were, in comparison with those of general paralysis,slight; an argument in favour of the view that progressiveparalysis of the insane was a primary disease of the neuronassociated with secondary inflammatory changes.Dr. WILLIAM HUNTER hardly thought the hyperpyrexia (in

one of the cases recorded) due to the pulmonary abscesses,since the largest of these was no bigger than a filbert (Dr.MANSON explained that one of these contained a dead parentworm; the others had probably a similar origin).

Dr. HARFORD-BATTERSBY from what he had seen of sleep-ing sickness, remarked that the enlargement of the lymphaticglands was one of regular occurrence and by the negroes wasregarded as in some way causing the disease, for which reasonsome kind of native operation was carried out upon them. Hethought, however, that the successful cures after such pro-cedures rested upon the removal of glands enlarged from othercauses. He had never heard of Europeans being attacked.The accessions of fever accompanying the disease were notmalarial, since they were not benefited by quinine.

CARD SPECIMENS.Dr. F. W. ANDREWES and Dr. H.1MORLEY FLETCHER: Organs

from Cases of Human Plague.-Mr. S. G. SHATTOCK: Culturesof B. Coli, B. Typhosus, etc., rendered permanent by meansof formalin vapour.-Dr. F. TooGOOD: (i) Hydronephrosi-s;(2) Aneurysm of Aorta perforating the (Esophagus.

CLINICAL SOCIETY OF LONDON.Sir R. DOIUGLAS POWELL, Bart., M.D., F.R.C.P., President,

in the Chair.Friday, October 13th, 1899.

NEW VOLUM1E OF TRANSACTIONS.ON assuming the chair for the first time, the PRESIDENTremarked that he would defer making a formal address untilhe had witnessed more of the work of the Society. He pre-sented the volume of Transactions just being issued, whichcontained the proceedings of last session, and he consideredit an eloquent proof of the good work done by the Society.A third of the volume was occupied by the descriptions ofcases exhibited on the clinical evenings.

ACUTE STREPTOCOCCAL MENINGITIS SUPERVENING IN THECOURSE OF CHRONIC PARENCHYMATOUS NEPHRITIS.

Dr. ROLLESTON described the case of a man, aged 22,admitted on the eighth day of his illness with a temperatureof 1030, but without any definite evidence as to the nature ofhis illness, which had begun with tonsillitis. He was quitefree from headache on admission, but the next day had twofits, passed into a condition of cerebral irritation, and diedwithin 24 hours. The necropsy showed extensive purulentmeningitis, due to streptococcal infection, and an acutenephritis on the top of chronic parenchymatous nephritis.No streptococci were visible in microscopic sections ofthe kidney, so the acute renal changes might have beentoxic. But, inasmuch as cultures were not made from thespleen or heart's blood, it could not be certainly said that thestreptococcal infection was confined to the meninges of thebrain. Terminal infections in renal disease were known tobe common in the lungs, pleura, and pericardium, but not inthe meninges. In Flexner's statistical study of terminal in-fections in chronic heart or kidney disease, the few cases ofmeningitis that occurred were almost always due to pneu-mococci. Flexner had shown that in chronic renal diseasethe bactericidal power of the blood was diminished, and thatterminal infections were therefore very liable to occur. Thiscase was remarkable for the unusual site of the terminalinfection, and for the latency of the meningitis. The tonsilswere possibly the source of infection.In answer to the PRESIDENT, Dr. ROLLESTON'stated that the

amount of urine passed was fairly copious.Dr. FRED.'J. SMITH remarked that cases of purulent mening-

itis from such a cause were extremely rare; he had neverseen one of the kind in the post-mortem room. But whilstpurulent meningitis rarely supervened in the course of renaldisease, pericarditis and pleurisy were common. Consideringthat tuberculous meningltis, commencing at the tonsils, wasfairly common, no other trace of tubercle, except that in thetonsils and cervical glands, being sometimes found in thebody, it was probable that in this case the tonsils were theactual seat of the streptococcal invasion.ANEIURYSM OF THE FIRST PART OF THE ARCH OF THE AORTA

PROJECTING INTO THE RIGHT AXILLA.Dr. T. CaURTON (Leeds) related the case of a man, aged 53,

admitted June 15th, I898, with a painful swelling on the rightside of the chest, extending from the mid-axillary to thenipple line, half the size of a cocoanut, the Seat of well-markedexpansile pulsation. It was first noted two years before, buthe only left off work three months ago on account of pain inthe right arm. He had been confined to bed for a fortnight,was feeble, and had anginal attacks. Aneurysm was diagnosed.An aortic regurgitant murmur was heard over the fourth costalcartilage. Syphilis was denied. The aneurysm had beenthought by a surgeon to be of axillary origin, but a residentbelieved it to be aortic, the diagnosis turning upon the effectof pressure upon the subelavian artery. On palpation, how-ever, a slight heaving could be felt from the tumour to thesternum, and this area was dull. The heart's impulse wasfelt in the sixth space, if inch external to the left nippleline. The bruit was fine and whiffing, not suggesting a largeregurgitation. There were no other marked pressure signs.The patient died on July 5th with symptoms of in-ternal heemorrhage. Post mortem the heart was found enlarged,chiefly the left ventricle; the mitral valve was normal,the aortic cusps were rather thick, but presented no

9

Tuu BmgYMK I10 KUDICAX JOUNISAXI OBSTETRICAL SOCIETY OF LONDON. I OCT. 21. 189.

marked deformity. The cavity was not much enlarged, butthe muscle was thick. The first inch of the aorta was fairlygood, but beyond it was greatly dilated, even within the peri-cardium. Beyond the pericardial attachment the first partbulged outwards and downwards. Just outside the peri-cardium on its outer aspect was a long narrow slit leading intoa sac measuring 51 by 4* by 3* inches, having a thick liningof solid clot. At the upper and inner part of the sac was aSmall opening I inch in length, from which blood had escapedinto the pleura at the upper and posterior part of the thorax.The third and fourth ribs ap earea to have been broken in theanterior axillary region, and the remains of the broken andseparated parts were apparently contained in the wall of thesac. The ribs were intact as to their outer surfaces for two orthree inches. The aneurysm lay wholly in front of the lung,the inner face of the upper lobe being closely adherent thereto.He pointed out as an unusual feature the point of projection ofthe aneurysm projecting into the right axilla, of which he hadbeen unable to find another example.

Dr. F. J. SmITH thought that the loudness of a bruit was notcommensurate with the amount of regurgitation, which wasproportionate, not to the amount of bruit, but to the severityof the clinical symptoms. He asked what was the weight ofthe heart, and doubted if an aneurysm of the arch or descend-ing aorta per se, and apart from valvular disease and regurgita-tion, had any effect on the weight of the heart. Did Dr.Churton consider that the aneurysm alone had led to hyper-trophy of the heart P The direction of the aneurysm was ananatomical accident, so to speak.Dr. CHAPMAN referred to Gross's dictum that in the bruit

of aortic regurgitation, if the second sound far exceeded thefirst, the regurgitation was extensive; but this rule did notapply to mitral regurgitation.

Dr. ROLLESTON said there was much difference betweenregurgitant murmurs of the mitral and aortic valves. In theformer case there was little or no relation between the loud-ness of the murmur and the amount of the lesion; but therelation between the two conditions was usually fairly pro-portionate in aortic regurgitation. In the absence of renaland cardiac disease aortic aneurysm did not, in his opinion,lead to hypertrophy of the heart.

Dr. PERCY KIDD also agreed that the loudness of the bruitwas not proportional to the loudness of the regurgitation, butthat the severity of the latter could be estimated by theclinical symptoms, and especially by the pulse. He had nowunder his charge at the London Hospital a man in whom theaneurysm bulged from the posterior wall of the arch, causingparalysis of muscles served by the recurrent laryngeal nerve,while there was a pulsating tumour over the scapula. In thatcase there was granular kidney.The PRESIDENT said it was curious how large an amount of

bone might be absorbed in these cases without the productionof much suffering. He cited a case in which there was pulsa-tion through the scapula, the swelling being just beneaththe skin, with very little sufferin . He agreed that theamount of bruit gave one very little idea of the severity of thevalvular trouble unless the clinical symptoms were also takeninto account. He thought it was pretty well settled thataneurysm of the aorta did not of itself cause cardiac hyper-trophy.

Dr. CHURTON, in reply, quite agreed that hypertrophy ofthe heart did not always follow aneurysm. There were twosigns which he considered indicative of severe aortic regurgi-tation, namely, obvious enlargement of the heart downwardsand to the left, so that the regurgitant bruit was heardloudest not over the third or fourth costal cartilage but overthe fifth or sixth left cartilage. Bad kidneys or bad arteriesalone did not always produce hypertrophied heart, althougheither condition usually had that effect; but he believed thecombination of the two conditions invariably caused hyper-trophy.OBSTINATE ANJEMIA ASSOCIATED WITH PECULIAR TROPHIC

DISTURBANCES AND WITH DOUBTFUL THROMBOSIS OFTHE SUPERIOR LONGEITUDINAL SINUS.

Dr. F. J. SMITH described the case of a girl, aged ig,who first came under observation in I895, when she improvedunder iron. In I896, while taking large numbers of Blaud'spills she developed features of peripheral neuritis. In I898'he suffered from warts on one hand, which showed peculiar

phenomena of growth and decay. In I899 she became muchworse, and was admitted with a grave degree of anaemia, andwhile in hospital developed most peculiar nervous symptomsconsisting of (i) a prolonged condition of serious interferencewith the respiratory mechanism, with periods of hours of rapidbreathing (66 or more per minute), alternating with hours ofvery slow breathing.; (2) intermittent fits of unconsciousnesswith convulsive movements of face and right arm and leg.No treatment seemed of any avail, but the patient graduallyimproved until headache and pain in the legs were her onlycomplaints. Incisions down to the bone of both tibise relievedthe latter; nothing had touched the former. Dr. Smith sum-marised the points of interest in the case as follow: (i) Itsextreme intractability; (2) nervous phenomena, apparentlyperipheral; (3) nervous phenomena, apparently of centralorigin.In answer to the PRESIDENT, Dr. Smith stated that the

incisions over the tibiae revealed no effusion of blood orpus nor any tumours.Dr. KIDD had seen the case in hospital and considered it

very puzzling; he had inclined to consider the symptoms dueto thrombosis.

Dr. NORMAN DALTON formerly thought thrombosis rare inanlemia, but this year he had seen three cases. A youngwoman with ansemia died last December, and he foundthrom-bosis of all the cerebral sinuses. This year another girl,markedly annemic, had great pain in the arm, and the veins ofthe part contained a thrombus. Whilst only this week hehad seen a woman, aged 23, with persistent headache over thelongitudinal sinus, and numbness and movements of the leftarm. These symptoms he thought might be due to throm-bosis of the longitudinal sinus. In that case, as in othercases of ansemia which did not readily yield to treatment,there was a suspicion of congenital syphilis.

Dr. ROLLESTON suggested that the case resembled one ofStokes-Adams disease.Dr. SAVILL related the case of a boy, aged 15, with extreme

ansemia, a little cedema around the ankles, a persistent louddouble cardiac murmur, and intermittent high temperature.These symptoms persisted for seven or eight months, and hedied. At the necropsy nothing was found to account for thesymptoms until the head was opened, when on the front ofeach cerebral lobe near the longitudinal sinus a gumma wasdiscovered. Stripe were then found upon the cornese, and ex-amination of the bones revealed several gummata. The casewas evidently one of congenital syphilis.Dr. C. R. Box said that two years ago a case was admitted

Into St. Thomas's Hospital, under Dr. Payne, in the laststage, as it was supposed, of pernicious anaemia. The redcorpuscles were considerably under a million, and there wasa great increase in the eosinophile cells. A serpiginous ulcerwas detected on the soft palate, which gave the indication fortreatment, and, under iodide of potassium, the patient in thecourse of a month left the hospital quite well. He relatedanother case with some thickening of the tibia, but onexamining the blood no increase in the eosinophile cells wasfound. That patient died, and the ordinary signs of per-nicious ansemia were found post mortem.Dr. SMITH, in reply, admitted that the possibility of

syphilis had not occurred to him; he would examine thepatient again, bearing in mind the suggested diagnosis, andwould give antisyphilitic remedies if the case provedsuitable for their administration. The patient certainlyalways had spongy gums, but her teeth and nose were good.He promised to exhibit the patient at a clinical evening, andto add a postscript to the present report of the case before itspublication in the Transactions.

OBSTETRICAL SOCIETY OF LONDON.ALBAN DORAN, F.R.C.S., President, in the Chair.

Wednesday, October 4th, 1899.HYDATIDIFORM DEGENERATION OF THE CHORION.

DR. WILLIAMSON read a paper in which he reviewed brieflythe earlier views of the pathology of the condition. Hedescribed the development of the chorionic villi, and thechanges which occurred in them when undergoing myxomatousdegeneration, the changes as observed by himself agreeingalmost entirely with those previously described by other

OCT. 21, I899.] OBSTETRICAL SOCIETY OF LONDON.

observers. The " myxoma fibrosum" of Virchow was described,andthe author gave his reasons for regarding this condition asclosely allied with hydatidiform mole. The question of thepriority of the degeneration of the chorion or the death of theembryo was discussed, and the conclusion arrived at thatdegeneration of the chorion usually preceded the death of theembryo. The relation of hydatid moles and deciduomamalignum was discussed. The author gave reasons for doubt-ing the doctrine of Spiegelberg with regard to the fcetal originof the hydatidiform disease, and quoted cases of repeatedhydatidiform molar pregnancies occurring in the samewoman. The usual naked-eye appearances of the mole weredescribed. The author endeavoured to ascertain (i) thefrequency of the occurrence of the condition, and (2)the effects of (a) age, (b) multiparity, (c) rapid child-bearing upon its production; concluding that: I. Its approxi-mate frequency may be once in 2,400 pregnancies; 2, thathydatidiform pregnancy may occur at any time duringthe child-bearing period, the age of the woman having verylittle influence; 3, that the condition is more frequent inthose who have borne few children than in those who haveborne many; 4, that it is not the rule for previous preg-nancies to have followed upon one anotherwith great rapidity.An inquiry was then made into the presence or absence of theusual signs and symptoms of normal pregnancy under thefollowing heads: (I) Amenorrhcea; (2) vomiting; (3) activityof breasts; (4) blue coloration of vaginal mucous membrane;(5) softening of cervix; (6) uterine tumour; (7) uterinetumour and feetal heart sounds. The conclusion was that allthese symptoms and signs were usually present excepting theuterine 8-soupe and foetal heart sounds, but sometimes thesemight be heard; whilst, on the other hand, the only signwhich was constantly present was enlargement of theuterus. The distinguishing features of the condition werethen described under the following heads: i. The size andother physical characters of the uterus, two classes ofcases being shown to exist: (i) those in which theuterus was larger than would be expected from the probableduration of the pregnancy, (2) those in which the uterus wassmaller, another feature sometimes present and of import-ance was uterine tenderness; 2, vaginal discharges, with orwithout the cysts; 3, haemorrhage. The author then dis-cussed the diagnosis, the conditions likely to be mistaken forhydatidiform mole being: (i) Concealed accidental heemor-rhage and placenta praevia; (2) the discharge of a pelvichydatid through the vagina; (3) hydramnion, especially ifcombined with hydrorrhoea gravidarum. Cases in whichdifficulty had arisen were recorded. The complications metwith were described: I. Albuminuria, a frequent complication,in which two forms were to be distinguished: (a) one form inwhich the prognosis was good in which blood and epithelialcasts were not present in the urine, (b) one form in whichthe prognosis was bad and in which these structures werefound in the urine; 2, haemorrhage, seldom fatal in itself;3, sepsis-sapraemia, septicsemia, and pyeemia all being fre-quent complications. Prognosis: The mortality of the whole25 cases was 20 per cent. The mortality of the IO consecutivecases from St. Bartholomew's Hospital was 30 per cent.Dr. HERMAN thought Dr. Williamson's analysis of his cases

was exceptionally valuable, but he was surprised at the highmortality reported He did not think the mortality amongcases of this disease in the London Hospital anything like so

high. His own experience was that in most cases when thecervix was dilated and ergot administered the mole wasexpelled, and that patients got *Well. He did not rememberever having had to perform any intrauterine manipulation toget away such a mole. In a few cases the existence ofmyxomatous degeneration had been suspected, but in most ithad not been thought of until the characteristic vesicles hadbeen seen in the discharges.The PRESIDENT called attention to the frequency of uncon-

trollable vomiting in association with hydatidiform mole;cases illustrating this had also been published by Brindeauand Bud. Keiffer traced vesicular mole to proliferatingarteritis, which modified the development of the products ofconception; this pathological change -he attributed to theabuse of emmenagogues early in pregnancy.- Neumann,Marchand, and Ludwig Fraenkel brought forward strongevidence that deciduom developed fromi relics of bydatidi-

form mole. Marchand was also a strong sulpporter of themolar theory as to the origin of deciduoma, dissenting fromthe opinion freely expressed at a meeting of the ObstetricalSociety in I896, and since then supported by Veit.Dr. GRIFFITH referred to the rarity of myxoma fibrosum as

in his opinion more apparent than real, the condition beingeasily overlooked in cases of fleshy mole unless carefullylooked for. He asked if any Fellow present could say he haddiagnosed, not merely suspected, a case in the absence of theextrusion of the characteristic cysts. He referred to thedanger of perforation during attempts to remove the moleentirely.Dr. HIUBERT ROBERTS asked whether Dr. Williamson con-

sidered the condition to be of maternal or feetal origin, andwhether he regarded it as a new formation or as a degenera-tion. He referred to Dr. Eden's observations, and pointedout that vascular degeneration had been found in the villi ofa normal placenta. He asked whether any such changes hadbeen observed in the stems of the degenerated chorionic villi.He thought that Dr. Williamson had not considered fullyenough the possible relation of hydatid moles to deciduomamalignum.

Dr. HEIRBERT SPENCER said that Dr. Williamson's methodof determining the frequency of hydatidiform; degpneration by-comparison with the number of cases of midwifery attendedfrom the same hospital as that in which the moles occurredwas a very fallacious one, and the proportion thus obtained,was of no value whatever in estimating the rarity of the,affection. The diagnosis from accidental haimorrhage andplacenta praevia was sometimes very difficult, and in -the'absence of the cysts (which were rarely passed) was generallyof the nature of a guess. He regarded abdominal ballotte-ment as of some value in the diagnosis, a fcetus being rarelypresent in cases of hydatidiform mole.

Dr. JOHN PHILLIPS wished to emphasise the difficulty ofdiagnosis between concealed haemorrhage and vesicular mole.He had seen several cases treated, and was not aware of anyseptic complications, whether treated by tents or artificiallyemptying the uterus. He had never met with a case in whichthe cysts were passed in the discharge during any period ofthe illness.

Dr. LUDWIG FRAENKEL (Breslau) thanked the Society forhaving permitted him as guest to hear Dr. Williamson's in-teresting communication. The author had only brieflytouched upon the relation of hydatidiform mole to deciduomamalignum. If he understood the author rightly he agreedwith the opinion expressed in the form of a resolution at thisSociety four years ago, that deciduoma malignum was an ordi-nary sarcoma of the uterus pregnancy, and, like Virchow, re-garded the disease as myxoma of the chorionic villi. On theother hand, the great majority of German authors regarded it assurely proved that deciduoma malignum arose from the epi-thelium of the chorionic villi, because the connection of thegrowth elements with the epithelial covering of the villi hadbeen in several cases directly observed under the microscope.Hydatidiform mole was, according to recent researches, not a

true myxoma, but a myxomatous degeneration of the stromaof the villi, with great overgrowth of the chorionic epithelium;it was really a chorio-epitheliomabenignum. If the remains ofhydatidiform mole underwent malignant development thereoccurred a chorio-epithelioma malignum. Dr. FraeAel re-

ferred to a case of his own, and another of which he had read,of the association of hydatidiform mole with double ovariancystoma.

Dr. HEEwooD SEMH said he thought there was a specimenof hydatidiform degeneration of the chorion at the Hospitalfor Women, and as far as he remembered it was diagnosed assuch.Dr. WILLIAMSON replied.

SPECIMENS.The following specimens were shown: Mr. J. B. BUTTON;

(i) A case of Rotation and Impaction of a Myomatousj Uterus ;

(2) a Tumour of the Mesometrium, weighing 22 lbs; (3) aMyomatolus Uterus, weighing 26 lbs., successfully removedfrom a woman, aged 74.-Mr. ROBERT WISE: A photograph ofa very stout woman, aged 49, with Large Pendulous UterineTumour and a Lipoma as big as a Melon below the RightBreast.

[r T*. Batmuu 1'CAL10 J@uNNAX

LIVERPOOL MEDICAL INSTITUTION.

LIVERPOOL MEDICAL INSTITUTION.W. MACTIE CAMPBELL, M.D., President, in the Chair.

Thursday, October 5th, 1899.USE AND ABUSE OF THE MIDWIFINsY FORCEPS.

THE PRESIDENT delivered an address on the midwiferyforceps as used and abused. Whatever theories might beheld as to the proper use of the midwifery forceps, therecould be no question that their invention was the greatestadvance in the obstetric art up to the beginning of the seven-teenth century. One could picture for oneself what practicemust have been without them by the study of the olderbooks on midwifery, when the instruments must have beenin use tentatively for half a century. The practitioner couldonly resort to Pare's drealdful hooks or the tire-tete-involvingcertain death to the child and injury to the mother-or to thecrochet. The invention of the forceps was alluded to and itsdevelopment down to the axis-traction forceps of modern dayswas traced. For a long time artificial aid was looked upon asthe opprobrium of midwifery, and there was a real fear ofblame to the surgeon whether the child was dead oralive and injured. -Writers of early times spoke of themidwives' strictures with awe, and dreaded to be calledbutchers. The patients, taught by the nurses, gave up hopewhen a surgeon was called in, so that it became common touse instruments secretly. Mauriceau quoted as a saying ofhis day, " When a man comes in one or both must die."Smellie gave elaborate instructions as to how best to eludeobservation. The forceps were carried in the pockets, and thepatient was covered with a sheet, the instrument brought-out under its cover and laid on the bed. Then surreptitiouslyunder the sheet they were introduced, used, and as secretlyxemoved, being placed dirty in the same pockets, all withoutthe watchful midwife or the equally suspicious friends know-ing what had been done. How different from modernpractice,when the suggestion of artificial aid often came from the.patient or her anxious friends. Thequestion when aid should-be given was an early controversy, and still continued. Aftergiving the opinions of many writers, he alluded to his ownpractice by stating that (i) a prolonged first stage was alwayssafe to mother and child, provided the membranes were intact.and the presentation natural; (2) during that stage it wasseldom necessary or advisable to give an aniesthetic ; (3) if amalpresentationwere diagnosed it might be necessarytocorrectit by manipulation, or if the corrected presentation did not re-main permanent, to rupture the membranes and possibly turnor apply the long forceps; (4) that exhaustion was sometimesfound in a protracted first stage, especially where the waterswere lost prematurely, and it might be needful to dilateand extract, or dilate in extracting by the forceps.When the second stage was fully entered upon, and,voluntary efforts accentuated the pains, anaesthetic (chloro-form invariably) was given with each pain. If during onehour in multiparse, or an hour and a half in primipare, therezwas evident progress, things were left to Nature plus chloro-form, chloroform being pressed only when the head stretchedthe perineum. If, however, during that time (i) no progress-was made, (2) the mother's pulse became rapid, or (3) thechild by its movements or its pulse showed signs of ex-'haustion, then he applied Braithwaite's short forceps anddelivered. These forcep3 were extremely handy, very light,and could be applied with a minimum of fuss. It was possibleto pass them without even bringing the patient to the edge ofthe bed : the lower blade first, then the upper posteriorly, andgradually edging it round; but this manceuvre was seldomrequired. The head could be brought down slowly or quicklyaccording to need, and when the head was on the perineumthe extracting power could be applied by the left hand be-tween the patient's thighs, with as little separation of thethighs as possible. He deprecated flexion and abduction ofthe thighs by the nurse, being convinced that the proceedingwould render the perineum more tense and rupture morelikely.. When the vertex had well filled the vaginal orifice heremoved the forceps and allowed Nature to finish if not tooboisterous. If delay then occurred, a modified " Ritgen"manipulation pressing post-anally upon the face or chin wasetmployed. he did not look upon such a case as re-quiring an after-douche unless for special causes, suchas meconial discharge or a dead child, and was content to rely

LOOT. 21, i899.

upon a boric acid or iodoform pessary inserted twice daily.He had conducted 243 such cases, with the loss of two childrenand no maternal death; consultation cases were excluded inwhich, of course, the mortality was higher. He attacked thestatement that " gynaecology had become so largely surgical asthe direct result of surgical interference in midwifery practice,"made some time ago by a professor of midwifery, and pro-duced opinions and statistics to controvert it. In conclusionhe stated that with forceps many evils immediate and remotewere avoided with ansesthesia; they must be more frequentlyused, and with asepsis and antisepsis their safety wasincreasing day by day.Mr. JOHN NEWTON proposed a vote of thanks to the President

for his able address. This was seconded by Dr. CATON, andcarried unanimously.

SUPPER AND SMOKING CONCERT.'The members were entertained by the President at supper,

which was followed by a smoking concert, and a very enjoyableevening was passed by those present.

MANCHESTER MEDICAL SOCIETY.-A meeting of this Societytook place on October 4th, Mr. W. THORBURN, F.R.C.S. (Vice-President) in the chair.-Dr. WILD gave a short communica-tion on the Etiology of Tuberculosis of the Skin.-Mr.SOUTHAM showed a girl, aged 7 years, who four years and a-half previously had sustained a Simple Fracture of the Tibiaand Fibula at the junction of the middle and lower third. Itwas treated in hospital in the ordinary way by means ofsplints, and a plaster-of-paris bandage was afterwards applied,but osseous union did not take place. The child had beenunder treatment continuously since the receipt of the injury,the fragments having been rubbed together and hammeredseveral times under anmesthesia, and on two occasions the endsof the bones had been resected and wired. At the presenttime the union, though still fibrous and allowing of slightmovement at the seat of fracture, was decidedly stronger thanit was six months ago; it was not, however, sufficiently firmto allow any weight to be borne on the leg, which was some-what wasted and about 2 inches shorter than its fellow. Nocause could be found either locally or constitutionally toaccount for the want of bony union.

GLASGOW SOUTHERN MEDICAL SOCIETY.-The openingmeeting for the session I899-I900 was held on October 5th,Dr. R. H. PARRY in the chair. There was a large attendanceof members. Dr. C. E. ROBERTSON, the representative of theSociety to the Victoria Infirmary, gave an interesting accountof the work done by the Board of Directors during the year,dwelling particularly on the improvements carried out at theBellahouston Dispensary. At the conclusion of his addressthe Treasurer, Dr. W. MCMILLAN, presented his financialstatement for the year, which showed a surplus of over £25.The Society then proceeded to the election of officials inroom of those retiring, and as now constituted the listof office-bearers of the Society was as follows :-lonoraryPresident: William Macewen, M.D., LL.D., F.R.S. President:Hugh Kelly, M.D. Vice-Presidents: Thomas W. Jenkins,M.D., William Watson, M.D. Treasurer: William McMillan,M.B., C.M. Secretary: John Fraser Orr, M.D. Editorial Secre-tary: Andrew Wauchope, M.B., C.M. Seal Keeper: JohntStewart, M.D. Extra Members of Council: Robert Pollok,M.B., C.M., Alexander C. McArthur, M.B., C.M., DuncanMcGilvray, M.B., C.M. Court Medical: Robert H. Parry, M.D.,John Dougall, M.D., Robert W. Forrest, M.D., EdwardMcMillan, L.R.C.S.Edin. Representative to Victoria Infirmary:Charles E. Robertson, M.D.

FORFARSHIRE MEDICAL AsSOCIATION.-At a meeting held onOctober 6th in the University College, Dundee, Dr. GRANT(Glamis), President, in the chair.-Dr. J. W. MILLER askedleave to propose the following resolution:That this meeting of the Forfarshire Medical Association desires to

record its deep sense of the loss which the Association has sustained inthe death of Dr. Johnston (Kair) at the advanced age of 85, and itsappreciation of the benefit which the Association derived from his con-stant and active support since its foundation.

In doing so he mentioned that Dr. Johnston had been

TxuBa JoiII I 12 xurnc". JOURNALJI

=

OCT. 21, isgg]1 SOCIETIES. r Tu B2mus XLMxDxc&L JouRNAL 3

P?resident twice, was one of the original members of the

Association, and was present at its first annual meeting held

in Dundee, in July, I859. Dr. TEMPLEMAN, Vice-President,

seconded this resolution, which was unanimously adopted,

and it was also agreed that an excerpt of the minutes be sent

to Dr. Johnston's niece at Kair House.-Dr. FOGGIE showed a

patient aged 28, who at every pregnancy except the first

suffered from an Affection of the Nails which he thought most

resembled psoriasis.-Dr. GRAY showed Three Casts of Con-

genital Deformities in an adult and also one of the Hands of a

child in which the fingers were found at the apices and a

,cast of a large double inguinal hernia.-Mr. GREIG showed a

cast of Congenital Suppression of Digits.-Professor KYNOCHshowed (i) Uterus removed from a patient, aged 56, suffering

from prolapse which had resisted other treatment and stated

four months after the hysterectomy a cystocele existed; (2)

a Multilocular Ovarian Cyst removed from a patient aged 3I; (3)

a Papillomatous Ovarian Cyst removed from a patient 4,months pregnant, with no bad symptoms after operation; (4)

specimenshowing EarlyVesicularDegenerationof the Chorion;(5) Stratz's speculum.-Dr. BUIST showed: (i) Ovaries with

subperitoneal cysts removed for persistent pelvic pain

follow gonorrhcea; (2) a Collection of Ovarian Cysts in one

of which there were some solid parts showing medullary

cancer on microscopic examination. Dr. Buist gave the

further history of two symphysiotomies which had been

reported in the BRITISH MEDICAL JOURNAL, Septem-

'ber, I898. The first patient, aged 27, had had three

confinements, but the children were stillborn in the first two,

and the child lived sixteen hours in the third in which labour

had been induced at seven and a-half months. At her fourth

pregnancy in February, I897, Dr. Buist performed symphysio-

tomyby Frank's method and a live child was born, which how-

everdied of bronchitis fourteen days later. In August, I899,she was confined normally of twins, both living. The second

patient, aged 21, rachitic, was delivered of a healthy child

still living after symphysiotomy by Ayre's subcutaneous

method in March,I898, after having been in labour for two

days. On Julysth last, after being in labour thirty-six hours

and with her pulse at 120, she had chloroform and was put in

Walcher's position and a healthy child was born naturally.

Both had done well since. Professor KYNOCH in discussing

the paper thought it was very important that the further

history of successful symphysiotomies should be reported, as

there was evidently a feeling against this operation. Dr.

BuIST, in reply, said he thought that in the poorer classes,

where good nursing was not available, symphysiotomy

should be carried out in preference to induced premature

labour.-Mr. GREIG read a paper on Ankylosis of the Temporo-

maxillary Articulation and its Relief by Excision of the

the Neck and Condyle of the Lower Jaw. He reported 4 suc-

cessful cases, of which was bilateral, and photographs of

these cases were shown with the limelight. He recommended

an incision, keeping the entire facial fibres and superficial

temporal artery in front, and showed how the operation could

be completed without the injury of any important structures.

He advocated the use of the chisel to divide the bone at the

condyle or if necessary at the coronoid process, and claimed

that by his incision the bone could be removed as low as the

inferior dental foramen with no iresulting facial paralysis.

Professor MACEWEN spoke, and Mr. GREIG replied.

ASSOCIATIONOF REGISTERED MEDICAL WOmEN.-At a meet-

ing held on October ioth, Mrs. SCHARLIEB, M.D., M.S.Lond.,

in the chiair, after the transaction of preliminary business,

Miss M. M. SHARPE, L.R.C.P.andB., showed a case of Psoriasis

of many years' standing, now under treatment by x rays, and

in which great improvement had taken place.-Miss ALDRICH

BLAKE, M.D., M.S.Lond., read notes of a case under her care

of Complete Prolapse of tie Rectum in a girl, aged 17, treated

by circular excision. The patient was admitted to the New

Hospital for Women on April ioth with a history that six

weeks before admission theprotrusion had suddenly come

down; she had had no previous rectal trouble. Apparently

no attempt had been made to replace it, and she sought no

advice until extensive sloughing caused such an offensive

discharge that the attention of others was attracted to her

condition. On admission a conical tumour, 4 inches in length,

and marked by deep transverse folds, wastound protruign

from the anus. The external surface of the tumour wasdirectly continuous with the surrounding parts without theexistence of any sulcus. The whole of the mucous coat, andin places the muscular coat, of the external layer of the pro-lapsed portion was sloughing, whilst the mucous membraneof the internal layer appeared healthy. The mass was irre-ducible. The day after admission circular excision of theprotrusion was performed. The peritoneum was carefullysutured where the cavity was opened on the front of the mass,and the upper segment of the bowel united to the lower byseveral interrupted sutures close to the anal margin. Thepatient made an uninterrupted recovery, and was dischargedon May ioth without difficulty in defiecation, and with noincontinence of faeces.-Mrs. GARRETT ANDERMON, M.D., reada paper on Diabetes.

BRISTOL MEDICO-CHIRURGICAL SOCIETY.-The annual meet-ing was held in University College, Bristol, on October I ith,Dr. ROXIIURGH and afterwards Mr.1HARSANT in the chair.-ThePRESIDENT (Mr. Harsant) gave his inaugural address, takingas his subject Medical Bristol in the Eighteenth Century.The address was full of interesting old customs, and manyamusing professional anecdotes were related. He had derivedmost of his information from some old manuscript volumes,by Richard Smith, in the possession of the Committee of theBristol Royal Infirmary, and he gave a graphic description ofsome of the physicians and surgeons of the infirmary a hun-dred years ago. Mr. PAUL BUSH (Honorary Secretary), Dr. B.ROGERS (Editorial Secretary), and Mr. L. M. GRIFFITHS(Honorary LibrariaD), read their respective reports for theyear, the latter mentioning that the Society's Library con-tained 8,I77 volumes, and received regularly i88 periodicals,and that the Bristol Medical Library, of which it formed apart, had altogether I9,982 volumes, with 224 currentperiodicals. The following officers were elected: President-Elect: Dr. D. S. Davies. Honorary Secretary: Mr. Paul Bush.Committee: Dr. Michell Clarke, Mr. J. Dacre, Dr. B. Rogers,Mr. Munro Smith, Mr. J. Taylor, Dr. H. Waldo.

PATHOLOGICAL SOCIETY OF MANCHESTER.-The annualmeeting was held on October iith, Dr. R. B. WILD,President in the chair. The following were elected officersforI899-I900: President: W. Thorburn, B.S. Vice-Presidents:E. S. Reynolds, M.D., A. Brown, M.D. Treasurer: T. A.Helme, M.D. &cretary: T. N. Kelynack, M.D. ResearchSecretary: F. C. Moore, M.D. Committee:J. G. Clegg, M.D.,W. E. Fothergill, M.D., J. E. Platt, M.S., A. W. W. Lea,M.D., F. C. Moore, M.D., W. A. Renshaw, E.J. Sidebotham,M.B., J. W. Smith, F.R.C.S. Auditors: F. J. H. Coutts,M.D., F. H. Westmacott, F.R.C.S. Specimens.-The followingspecimens were shown: Dr. BROOKE and Dr. WILD; Photo-graphs of Skin Affections.-Mr. BURGESS: (i) Duct Papillomaof Breast; (2) Carcinoma of Body of Uterus; (3) Uterus fivedays after Delivery.-Dr. DELAPINE: Series of Cultures ofMicro-Organisms.-Dr. FOTHERGILL: (I) Encephalocele; (2)Exomphalos.-Dr. HELME: (I) Myomatous Uteri Removed byAbdominal Hysterectomy; (2) Ovarian Cysts removed fromSubjects over 65 years of age.- Dr. ORR: (i) Rupture of LeftVentricle; (2) Tumour ofBrain; (3) Sarcoma of Liver; (4)Chronic Renal Disease with Impacted Calculi.-Mr. WHITE-HEAD: Sarcoma of Undescended Testicle.-Dr. EURICH: (I)Melanotic Sarcoma; (2) Kidneys and Suprarenals from TwoCases of Addison's Disease.-Dr. POWELL WHITE: Liver fromCase of Pyelophlebitis.

GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY.--At ameeting held on Octobergth, Dr. THOMAS BARR (President) inthe chair, Dr. RUTHERPURD showed aspecimen of a Meningo-cele from the Occipital Region, and the child from whom ithad been removed. He considered the prognosis interestingon the question of the ultimate benefit to the child from theoperation. The patient was imbecile, and he looked on themeningocele as merely a part of a general defect in the brainformation. As regarded the method of operation, upper andlower skin flaps had been raised and the pedicle transfixedand tied with interlocking sutures. The cyst was thencut away and the flaps sutured. Healing took place perprimam. In reply to a question by the PRESIDENT, Dr. Ruther-

I -- -

I14 MJCDIAL JOURNALI REVIEWS. [OCT. 21, 1899.

furd stated that he considered the mouth-breathing ofthe child concomitant of imbecility, apart from nasalobstruction, which might exist. Dr. Rutherfurd alsoshowed a specimen of CEsophageal Stricture of ValvularForm from a woman aged 30. The symptoms werevomiting, without relation to kind of food, the vomitedmatter varying in appearance from clear watery to greenishmaterial, evidently from the small intestine. The case was atfirst thought to be gastric, but a bougie was stopped at a pointI2- inches from incisor teeth. Gastrostomy by Witzel'smethod was performed, but fluid introduced into the stomachwas immediately vomited. She died thirty-six hours after theoperation. The stricture was caused by a valvular fold situ-ated within 2 inches of the cardia, and above it was a pouchcontaining a quantity of grumous material. Death was causedby incessant vomiting, and this was difficult to account forsave on the " reflex" theory. She had suffered from gastricsymptoms for six years, more pronounced during the last sixweeks. The stricture was probably traumatic in origin.-Dr.W. L. REID exhibited a specimen of Cancer of the Cervix forwhich vaginal hysterectomy had been performed. The broadligaments were ligatured by means of Dr. Reid's modificationof Jessett's pedicle needle. Dr. ALEC. R. FERGUsoN read areport of the pathological appearances.

REVIEWS,BURDETT'S HOSPITALS AND CHARITIES, I899. By Sir HENRYBURDETT, K.C.B. London: The Scientific Press. (Crown8vO, PP. 954. 58.)

WE welcome the appearance of this most valuable annualrecordof our hospital system, after an accidental delay forwhich its author apologises. We have no need to dwell on themerits of Sir H. BURDETT'S labours in the cause of hospitals,nor need one share all his opinions in order to be sensible ofthose merits. For instance, he seems to be in favour of ex-tending the " pay-system " to all existing hospitals-a doctrineto which we cannot assent. Still, In most of the main depart-ments of our voluntary hospital system Sir Henry will provea safe guide to the philanthropist, first, and above all, becausehe would keep that system a voluntary one, and would not bindthese great institutionslin the fetters of official control. Then,again, he is an advocate of liberal expenditure, as, indeed,has become necessary in these days of improved and morescientific treatment, and yet he deprecates that recklessnesswhich shows itself in too luxurious buildings and too numerousa staff of nurses, etc. He believes that the income of the me-tropolitan hospitals, taken in a lump, has increased since thePrince of Wales's Fund was started, and is increasing, thoughwe are not told that this increase is in a greater ratio thanthat of the population of the districts served by the hospitals.Of course, to this average increase there are exceptions in in-dividual cases, which are dealt with In this work to someextent; but, on the whole, we think the author proves hisassertion that the Fund has not hitherto had any injuriouseffect on the income of the metropolitan medical charities.But, as we have often contended, much still remains to bedone, before the benevolent intentions of His Royal Highnessare carried out, by the creation of a new class of small sub-scribers, and by raising the yearly income, distributable amongthe charities benefited, to between £100,000 to £15o,ooo, andby obtaining this income from such new subscribers withoutinterfering with the sums raised from old subscribers. To pro-mote this laudable end, the " League of Mercy " has been insti-tuted, and our author tells us that its progress "has beenmost satisfactory " up to July last. We shall look with interestfor the result of the present year's proceedings, both in regardto this League and as to the maintenance of the general fund.Many general maxims are laid down in this work, as to which

no doubt much discussion might be raised-such as the propor-tion to the total income which the cost of administration oughtnot to exceed--and which is here fixed at I per cent. for metro-politn general hospitalsa containing IOO beds or more, Io to2per cent. for those in the provinces, the same percentage

it $pWia4liospitals of the same size, and a maximum ofo20 per cent.'for smaller special hospitals. We take it that Sir2Ieny Burdett dedupes,these estimates from his large experi-

ence. There is nothing here to prove them, though we think theauthor's conclusion a very probable one, that every hospitalspending on administration more than a fifth of its incomeshould be regarded as suspect, apart from a proper explana-tion by the managing body.We will end with one quotation: " No metropolitan hospital

of repute need suffer severely from want of funds providingsufficient energy and capacity are exhibited by those who areresponsible for its administration " (p. 82). The doctrine isa comforting one to managers who are conscious of possessingthe requisite qualifications.The book needs no recommendation of ours to ensure it a

wide popularity, and as far as we can judge the present issueis up to the usual level of its excellence.

A TEXTBOOK OF ANATOMY. Edited by F. H. GERRISH, M.D.,Professor of Anatomy in the Medical School of Maine,Bowdoin College. London: H. Kimpton. I899. (Roy.8vo,PP. 917, 950 illustrations. 27s.)

THIS work on anatomy, written entirely by American ana-tomists, is published in the belief that students of anatomy"s hould neither be encouraged to depend upon pocketmanuals nor be compelled to resort to encyclop2edias." Thefacts throughout the work are generally accurate; here andthere, however, one meets with teaching which is notapproved by English anatomists. The special feature of thebook is the illustration. Many figures are copied fromTestut, but a large number have been specially executed forthis work. A very vivid and ingenious method of illustratingthe origin, course, and insertion of the muscles is mosteffective. A large proportion of the figures are coloured, andphotography has been used for the representation of specialsubjects.In the section dealing with the muscular system a novel

and scientifically accurate olassification has been adopted.Muscles are grouped with reference to their actions uponjoints. The change of nomenclature is incorrect and un-necessary. Of all the sections, that most worthy of specialcommendation deals with the brain, and has been written bythe editor. In describing the peripheral nerves we thinkthat use might have been made of Kocher's plates. Therelationship between the segments of the cord and thecutaneous distribution of nerves is surgically, and indeedmedically, of the utmost value and importance. Kocher'swork is probably the most accurate and most complete deal-ing with this subject.The description of the lymphatic system is, on the whole,

good, and is illustrated by some excellent figures which havealready appeared in Dennis's System of Surgery. Where thesurgical anatomy of the lymphatics is so supremely importantas in the breast and tongue and elsewhere, the descriptionmight have been more complete. Justice is not done to thework of Heidenhain and Kuttner.

NOTES ON BOOKS.City of Sheffield: Special Report on the Prevalence of Tuber-

c0lsts and the Measures for its Prevention. By JOHN ROBERT-SON, M.D., B.Sc., Medical Officer of Health. (I899. Sheffield:Loxley Brothers).-This admirable report was presentedrecently to the members of the Health Committee of Sheffield,and the corporation of that city is to be congratulated onhaving a medical officer of health who is able to state the casbfor the crusade against consumption in such clear, simple,temperate, and conclusive terms. The report begins by ageneral statement of the present scientific position of thequestion, written in such a terse and clear way that any non-medical reader could rapidly grasp the principles which wenow have to guide us. This is followed by some statistics,which are not overwhelming but are quite convincing. TwoIiagrammatic charts bring out much clearer than figures can

do the wholesale annual slaughter wrought by the bacillustberculosis in contrast to the comparatively insignificantIeath roll due to, say, scarlet fever or small-pox. One tableslwshs clearly the progress which has already been made inreducing the mortality to its present rate. The annual